Designing an automated clinical decision support system to match clinical practice guidelines for opioid therapy for chronic pain

Abstract Background Opioid prescribing for chronic pain is common and controversial, but recommended clinical practices are followed inconsistently in many clinical settings. Strategies for increasing adherence to clinical practice guideline recommendations are needed to increase effectiveness and reduce negative consequences of opioid prescribing in chronic pain patients. Methods Here we describe the process and outcomes of a project to operationalize the 2003 VA/DOD Clinical Practice Guideline for Opioid Therapy for Chronic Non-Cancer Pain into a computerized decision support system (DSS) to encourage good opioid prescribing practices during primary care visits. We based the DSS on the existing ATHENA-DSS. We used an iterative process of design, testing, and revision of the DSS by a diverse team including guideline authors, medical informatics experts, clinical content experts, and end-users to convert the written clinical practice guideline into a computable algorithm to generate patient-specific recommendations for care based upon existing information in the electronic medical record (EMR), and a set of clinical tools. Results The iterative revision process identified numerous and varied problems with the initially designed system despite diverse expert participation in the design process. The process of operationalizing the guideline identified areas in which the guideline was vague, left decisions to clinical judgment, or required clarification of detail to insure safe clinical implementation. The revisions led to workable solutions to problems, defined the limits of the DSS and its utility in clinical practice, improved integration into clinical workflow, and improved the clarity and accuracy of system recommendations and tools. Conclusions Use of this iterative process led to development of a multifunctional DSS that met the approval of the clinical practice guideline authors, content experts, and clinicians involved in testing. The process and experiences described provide a model for development of other DSSs that translate written guidelines into actionable, real-time clinical recommendations.http://deepblue.lib.umich.edu/bitstream/2027.42/78267/1/1748-5908-5-26.xmlhttp://deepblue.lib.umich.edu/bitstream/2027.42/78267/2/1748-5908-5-26.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/78267/3/1748-5908-5-26-S3.TIFFhttp://deepblue.lib.umich.edu/bitstream/2027.42/78267/4/1748-5908-5-26-S2.TIFFhttp://deepblue.lib.umich.edu/bitstream/2027.42/78267/5/1748-5908-5-26-S1.TIFFPeer Reviewe

Servant leadership as a driver of employee service performance: Test of a trickle-down model and its boundary conditions

Previous research has demonstrated the role of servant leadership, a leadership style emphasizing serving others, in promoting frontline employees’ service performance. It is unclear, however, how servant leadership by leaders at different organizational levels would exert such an influence. Integrating insights from both social learning theory and the trickle-down paradigm of leadership, we develop a cross-level model in which we argue that servant leadership by high-level managers could cascade downward through the organizational hierarchy to influence frontline employees’ service performance and that this trickle-down effect is contingent on the extent to which subordinates identify their leaders as embodying the organization. Using a matched sample of 92 supervisors and 568 frontline employees across 92 sub-branches of a large banking company, we found that servant leadership by high-level managers could indeed promote employees’ in-role and extra-role service performance through its effect on low-level supervisors’ servant leadership. We also found that this trickle-down effect was stronger when high-level managers and low-level supervisors were perceived by their subordinates as more fully embodying the organization. Implications, limitations and future directions are discussed

Formulation and performance of variational integrators for rotating bodies

Variational integrators are obtained for two mechanical systems whose configuration spaces are, respectively, the rotation group and the unit sphere. In the first case, an integration algorithm is presented for Euler’s equations of the free rigid body, following the ideas of Marsden et al. (Nonlinearity 12:1647–1662, 1999). In the second example, a variational time integrator is formulated for the rigid dumbbell. Both methods are formulated directly on their nonlinear configuration spaces, without using Lagrange multipliers. They are one-step, second order methods which show exact conservation of a discrete angular momentum which is identified in each case. Numerical examples illustrate their properties and compare them with existing integrators of the literature

Patient enablement requires physician empathy: a cross-sectional study of general practice consultations in areas of high and low socioeconomic deprivation in Scotland

<b>Background</b> Patient 'enablement' is a term closely aligned with 'empowerment' and its measurement in a general practice consultation has been operationalised in the widely used patient enablement instrument (PEI), a patient-rated measure of consultation outcome. However, there is limited knowledge regarding the factors that influence enablement, particularly the effect of socio-economic deprivation. The aim of the study is to assess the factors influencing patient enablement in GP consultations in areas of high and low deprivation.<p></p> <b>Methods</b> A questionnaire study was carried out on 3,044 patients attending 26 GPs (16 in areas of high socio-economic deprivation and 10 in low deprivation areas, in the west of Scotland). Patient expectation (confidence that the doctor would be able to help) was recorded prior to the consultation. PEI, GP empathy (measured by the CARE Measure), and a range of other measures and variables were recorded after the consultation. Data analysis employed multi-level modelling and multivariate analyses with the PEI as the dependant variable.<p></p> <b>Results</b> Although numerous variables showed a univariate association with patient enablement, only four factors were independently predictive after multilevel multivariate analysis; patients with multimorbidity of 3 or more long-term conditions (reflecting poor chronic general health), and those consulting about a long-standing problem had reduced enablement scores in both affluent and deprived areas. In deprived areas, emotional distress (GHQ-caseness) had an additional negative effect on enablement. Perceived GP empathy had a positive effect on enablement in both affluent and deprived areas. Maximal patient enablement was never found with low empathy.<p></p> <b>Conclusions</b> Although other factors influence patient enablement, the patients' perceptions of the doctors' empathy is of key importance in patient enablement in general practice consultations in both high and low deprivation settings

Phase structure of black branes in grand canonical ensemble

This is a companion paper of our previous work [1] where we studied the thermodynamics and phase structure of asymptotically flat black $p$-branes in a cavity in arbitrary dimensions $D$ in a canonical ensemble. In this work we study the thermodynamics and phase structure of the same in a grand canonical ensemble. Since the boundary data in two cases are different (for the grand canonical ensemble boundary potential is fixed instead of the charge as in canonical ensemble) the stability analysis and the phase structure in the two cases are quite different. In particular, we find that there exists an analog of one-variable analysis as in canonical ensemble, which gives the same stability condition as the rather complicated known (but generalized from black holes to the present case) two-variable analysis. When certain condition for the fixed potential is satisfied, the phase structure of charged black $p$-branes is in some sense similar to that of the zero charge black $p$-branes in canonical ensemble up to a certain temperature. The new feature in the present case is that above this temperature, unlike the zero-charge case, the stable brane phase no longer exists and `hot flat space' is the stable phase here. In the grand canonical ensemble there is an analog of Hawking-Page transition, even for the charged black $p$-brane, as opposed to the canonical ensemble. Our study applies to non-dilatonic as well as dilatonic black $p$-branes in $D$ space-time dimensions.Comment: 32 pages, 2 figures, various points refined, discussion expanded, references updated, typos corrected, published in JHEP 1105:091,201

Rotation and Spin in Physics

We delineate the role of rotation and spin in physics, discussing in order Newtonian classical physics, special relativity, quantum mechanics, quantum electrodynamics and general relativity. In the latter case, we discuss the generalization of the Kepler formula to post-Newtonian order $(c^{-2}$) including spin effects and two-body effects. Experiments which verify the theoretical results for general relativistic spin-orbit effects are discussed as well as efforts being made to verify the spin-spin effects

A frequentist framework of inductive reasoning

Reacting against the limitation of statistics to decision procedures, R. A. Fisher proposed for inductive reasoning the use of the fiducial distribution, a parameter-space distribution of epistemological probability transferred directly from limiting relative frequencies rather than computed according to the Bayes update rule. The proposal is developed as follows using the confidence measure of a scalar parameter of interest. (With the restriction to one-dimensional parameter space, a confidence measure is essentially a fiducial probability distribution free of complications involving ancillary statistics.) A betting game establishes a sense in which confidence measures are the only reliable inferential probability distributions. The equality between the probabilities encoded in a confidence measure and the coverage rates of the corresponding confidence intervals ensures that the measure's rule for assigning confidence levels to hypotheses is uniquely minimax in the game. Although a confidence measure can be computed without any prior distribution, previous knowledge can be incorporated into confidence-based reasoning. To adjust a p-value or confidence interval for prior information, the confidence measure from the observed data can be combined with one or more independent confidence measures representing previous agent opinion. (The former confidence measure may correspond to a posterior distribution with frequentist matching of coverage probabilities.) The representation of subjective knowledge in terms of confidence measures rather than prior probability distributions preserves approximate frequentist validity.Comment: major revisio

Looking backward: From Euler to Riemann

We survey the main ideas in the early history of the subjects on which Riemann worked and that led to some of his most important discoveries. The subjects discussed include the theory of functions of a complex variable, elliptic and Abelian integrals, the hypergeometric series, the zeta function, topology, differential geometry, integration, and the notion of space. We shall see that among Riemann's predecessors in all these fields, one name occupies a prominent place, this is Leonhard Euler. The final version of this paper will appear in the book \emph{From Riemann to differential geometry and relativity} (L. Ji, A. Papadopoulos and S. Yamada, ed.) Berlin: Springer, 2017

The relationship between sensory sensitivity and autistic traits in the general population.

Individuals with Autism Spectrum Disorders (ASDs) tend to have sensory processing difficulties (Baranek et al. in J Child Psychol Psychiatry 47:591–601, 2006). These difficulties include over- and under-responsiveness to sensory stimuli, and problems modulating sensory input (Ben-Sasson et al. in J Autism Dev Disorders 39:1–11, 2009). As those with ASD exist at the extreme end of a continuum of autistic traits that is also evident in the general population, we investigated the link between ASD and sensory sensitivity in the general population by administering two questionnaires online to 212 adult participants. Results showed a highly significant positive correlation (r = .775, p < .001) between number of autistic traits and the frequency of sensory processing problems. These data suggest a strong link between sensory processing and autistic traits in the general population, which in turn potentially implicates sensory processing problems in social interaction difficulties